The Management and Outcomes of Staphylococcus aureus Osteoarticular Infections Associated With Prolonged Bacteremia in Children

Introduction: Staphylococcus aureus is the predominant cause of acute hematogenous osteoarticular infection (AHOAI, osteomyelitis or bacterial arthritis) in children and is commonly associated with bacteremia. Current guidelines suggest that persistent bacteremia may warrant more aggressive treatment. We evaluated the outcomes of children with S. aureus AHOAI with respect to bacteremia duration. Methods: Children ≤18 years old with AHOAI secondary to S. aureus from 2011 to 2021 were identified through prospective surveillance studies at Texas Children’s and St. Louis Children’s Hospitals. Orthopedic complications included pathologic fractures, avascular necrosis, angular deformity and chronic osteomyelitis. Results: Five hundred four cases were included, of which 65% had a positive blood culture. The median duration of bacteremia was 1 day (interquartile range: 1–3 days). Children with prolonged bacteremia (≥3 days) had a longer duration of fever in the hospital, more often had methicillin-resistant S. aureus , pyomyositis and venous thromboses, and were less often transitioned to oral therapy. Duration of bacteremia was independently associated with nonmusculoskeletal foci of infection (adjusted odds ratio 2.07, 95% confidence interval: 1.28–3.32). However, the duration of bacteremia was not directly associated with orthopedic complications. Within the subset of patients with prolonged bacteremia, those who were transitioned to oral therapy had similar rates of readmission and orthopedic complications as those treated with prolonged intravenous antibiotics. Conclusions: Prolonged bacteremia in the setting of S. aureus AHOAI should prompt evaluation for other foci of infection. At least a subset of children with S. aureus AHOAI and prolonged bacteremia can be safely transitioned to oral antibiotics after a period of intravenous therapy with good outcomes.